What are the recommended lifestyle modifications and first‑line pharmacologic treatments for an adult with hypertension, including considerations for age, race, and comorbidities?

Hypertension Management in Adults

For most adults with hypertension, initiate lifestyle modifications immediately and start pharmacologic therapy with a thiazide or thiazide-like diuretic, ACE inhibitor or ARB, or calcium channel blocker—either as monotherapy for stage 1 hypertension or as combination therapy for stage 2 hypertension (≥140/90 mmHg)—targeting a blood pressure <130/80 mmHg in adults under 65 years. 1, 2

Lifestyle Modifications (First-Line for All Patients)

Lifestyle changes are the cornerstone of hypertension management and should be implemented immediately for all patients, regardless of whether pharmacologic therapy is initiated. 1

Dietary Interventions

• DASH dietary pattern: Consume 8–10 servings of fruits and vegetables daily, 2–3 servings of low-fat dairy products, limit saturated fat to <7% of total calories, and keep dietary cholesterol <200 mg/day. 1, 3 This pattern can reduce systolic BP by 8–14 mmHg. 3
• Sodium restriction: Limit intake to <2,300 mg/day (ideally <1,500 mg/day), which can lower systolic BP by 8–14 mmHg. 1, 3, 2
• Potassium supplementation: Increase dietary potassium intake through fruits, vegetables, and legumes. 1, 2

Physical Activity

• Aerobic exercise: Prescribe at least 150 minutes per week of moderate-intensity activity (brisk walking, cycling). 1, 3, 4 Regular exercise reduces BP by approximately 5 mmHg and decreases cardiovascular mortality by 7%. 4
• Resistance training: Include 2–3 days per week of resistance exercise. 4

Weight Management

• Weight reduction: Encourage weight loss in overweight or obese patients, matching energy intake to energy needs. 1

Alcohol and Tobacco

• Alcohol moderation: Limit to ≤2 drinks/day for men and ≤1 drink/day for women. 1
• Smoking cessation: Advise complete tobacco cessation at every visit using clear, personalized counseling. 1

Indications for Pharmacologic Therapy

Immediate Treatment Required

• Stage 2 hypertension (≥160/100 mmHg): Start medication immediately alongside lifestyle modifications. 3
• High cardiovascular risk: Initiate therapy for BP ≥140/90 mmHg in patients with established CVD, chronic kidney disease, diabetes, target-organ damage, or 10-year CVD risk ≥10%. 1, 3, 2

Delayed Treatment (After 3–6 Months of Lifestyle Modification)

• Stage 1 hypertension (140–159/90–99 mmHg) in low-to-moderate risk patients: Trial lifestyle modifications for 3–6 months before initiating medication. 1, 3 If BP remains uncontrolled, start pharmacologic therapy. 3

First-Line Pharmacologic Treatment

For Non-Black Patients

1. Initial therapy: Start with a low-dose ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily). 1, 3, 2, 5, 6
2. Add second agent: If BP remains uncontrolled, add a dihydropyridine calcium channel blocker (e.g., amlodipine 5–10 mg daily). 1, 3
3. Titrate to full doses: Increase medications to maximum recommended doses before adding additional agents. 3
4. Add thiazide diuretic: Incorporate hydrochlorothiazide 12.5–25 mg daily or chlorthalidone 12.5–25 mg daily, preferably as a single-pill combination. 1, 3, 2
5. Resistant hypertension: Add spironolactone 25–50 mg daily; if not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or a beta-blocker. 3, 7

For Black Patients

Black adults require different initial therapy due to physiological differences including suppressed renin-angiotensin-aldosterone system and altered sodium handling. 1

1. Initial therapy: Start with a thiazide-type diuretic (chlorthalidone 12.5–25 mg daily) plus a calcium channel blocker (amlodipine 5–10 mg daily), or a calcium channel blocker plus an ARB. 1 Thiazides and CCBs are more effective than ACE inhibitors or ARBs as monotherapy in Black patients. 1
2. Titrate to full doses: Increase to maximum recommended doses. 1, 3
3. Add third agent: Incorporate the missing drug class (diuretic or ACE inhibitor/ARB) to achieve triple combination therapy. 1, 3
4. Resistant hypertension: Add spironolactone or alternative agents as listed above. 3

Important caveat: ARBs are preferred over ACE inhibitors in Black patients because angioedema occurs 3 times more frequently with ACE inhibitors in this population. 1

Combination Therapy Considerations

• Most patients require ≥2 medications: Two or more antihypertensive agents are recommended to achieve BP targets, especially in Black adults. 1
• Never combine two RAS blockers: Do not use an ACE inhibitor plus an ARB together due to increased adverse effects without additional benefit. 3
• Single-pill combinations: Preferred to improve adherence. 1, 2

Blood Pressure Targets

• Adults <65 years: Target BP <130/80 mmHg. 1, 2
• Adults ≥65 years: Target systolic BP <130 mmHg. 1, 2
• Optimal target: Aim for systolic BP 120–129 mmHg if well tolerated. 3
• Time to goal: Achieve target BP within 3 months of initiating therapy. 3

Special Populations

Patients with Diabetes

• Lower BP threshold: Initiate drug therapy at BP ≥130/80 mmHg. 1
• Preferred agents: ACE inhibitors or ARBs are first-line due to renal protective effects. 1

Patients with Chronic Kidney Disease or Heart Failure

• Lower BP threshold: Start treatment at BP ≥130/85 mmHg (or ≥130/80 mmHg for CKD). 1
• Preferred agents: ACE inhibitors or ARBs for renal protection. 1

Hispanic Americans

• Standard treatment applies: Use the same algorithm as non-Black patients. 1
• Address barriers: Consider socioeconomic factors, limited access to healthy foods, and cultural preferences when counseling on lifestyle modifications. 1
• Heterogeneous risk: Recognize that cardiovascular risk varies by ancestry (Caribbean vs. Mexican/Central American origin). 1

Follow-Up and Monitoring

• During lifestyle modification phase: Follow up every 3–6 months. 3, 8
• After medication initiation: See patients every 4–6 weeks until BP is controlled. 3, 8
• Once controlled: Follow up every 2–4 months. 3
• Home BP monitoring: Encourage patients to monitor BP at home to confirm office readings and assess treatment response. 1

Common Pitfalls and How to Avoid Them

Measurement Errors

• Improper cuff size: Always use an appropriately sized cuff based on arm circumference; an incorrect cuff can falsely elevate or lower readings. 1, 8
• White-coat hypertension: Confirm diagnosis with home or ambulatory BP monitoring before initiating treatment. 3, 8
• Single-arm measurement: Measure BP in both arms at the initial visit and use the arm with the higher reading for all subsequent measurements. 3

Treatment Errors

• Premature medication: Avoid starting drugs in low-risk stage 1 hypertension before completing a 3–6 month trial of lifestyle modifications. 3
• Monotherapy in stage 2 hypertension: Most patients with BP ≥160/100 mmHg require combination therapy from the outset. 3, 2
• Inadequate dosing: Titrate medications to full recommended doses before adding additional agents. 1, 3
• Suboptimal drug combinations: Use agents with complementary mechanisms of action (e.g., RAS blocker + CCB + diuretic). 7

Adherence Issues

• Medication complexity: Simplify regimens using single-pill combinations whenever possible. 1
• Cost barriers: Address financial constraints, especially in resource-limited populations. 1
• Lack of follow-up: Arrange regular follow-up visits and provide clear instructions for home BP monitoring. 1

Screening for Secondary Causes

• Young adults (<40 years): Screen for secondary causes of hypertension, particularly in non-obese patients. 3 Common causes include renal artery stenosis, primary aldosteronism, pheochromocytoma, and obstructive sleep apnea. 7
• Resistant hypertension: Evaluate for secondary causes and interfering substances (NSAIDs, decongestants, excessive alcohol) in patients whose BP remains uncontrolled on ≥3 medications. 7